Monitoring Therapists: Ethical Or Unnecessary?

Monitoring the therapist throughout a study can be a complex and challenging task, but it is essential to ensure the quality and effectiveness of the therapy provided. Regular client feedback, also known as routine outcomes monitoring, has been found to improve therapy outcomes and facilitate therapist self-assessment. However, there is a disconnect between research and practice, with many therapists feeling that progress monitoring is not a high priority. This could be due to the subjective nature of progress monitoring data and the challenge of interpreting client feedback. Additionally, progress monitoring can trigger self-judgment and comparison, which may not accurately reflect a therapist's skill or performance. To address these challenges, therapists should view progress monitoring as a tool for professional growth and a way to improve clinical decision-making. By calibrating their clinical intuitions with client feedback, therapists can enhance their interpersonal skills, accuracy in relational attunement, and ability to contain and address difficult emotions. Furthermore, progress monitoring can be adapted to fit each therapist's style and integrated into their practice in a way that feels authentic and comfortable. Overall, while monitoring the therapist throughout a study can be a challenging task, it has the potential to improve therapeutic outcomes and should be approached with curiosity and creativity.

Therapists should monitor their own resistance to progress monitoring

Resistance in therapy is a complicated idea, originally created as a psychoanalytic concept by Sigmund Freud, who believed it was an unconscious opposition to revealing memories in psychoanalysis. In more general terms, resistance is anything that stops therapeutic change. It has traditionally been thought of as a client's unwillingness, either conscious or unconscious, to grow. However, more current definitions posit that resistance is not just the fault of the client, but is a product of the therapeutic relationship.

Therapists should be aware of their own resistance to progress monitoring because it can negatively impact treatment success. Resistance can take many forms, including arguing, interrupting, denying, ignoring, and physical withdrawal. It can also be covert, with clients claiming to be on board with the therapist's recommendations while keeping their disagreement hidden. Therapists should be attuned to even subtle signs of resistance in order to effectively address it and enhance collaboration with the client.

There are several ways to address and manage resistance. Firstly, therapists should get curious about their own resistance and reflect on their theoretical orientation and stance on the interaction between research and practice. They should also think about what client feedback is telling them and remember that progress monitoring data is not purely objective evidence. Instead, therapists should use it to calibrate their clinical intuitions and improve their clinical decision-making process.

Additionally, therapists should not evaluate themselves based on progress monitoring data, as it does not provide purely objective evidence. Instead, they should use it to grow and improve as practitioners, increasing their tolerance of clients' negative emotions and improving their ability to contain and address these feelings.

Finally, therapists should be authentic and creative in their approach to progress monitoring, adapting it to fit their own style and drawing on it to form conceptualizations and intervention strategies. By doing so, therapists can strengthen the therapeutic relationship and further treatment, encouraging client growth.

Therapists should be curious about what client feedback is telling them

Therapists can establish an atmosphere of feedback at the outset of therapy by explaining the rationale for requesting feedback and addressing any concerns clients may have. They can ask questions such as "How do you feel about how today's session went?" or "Did you struggle with anything in our session today?". Therapists should also ask about both positive and negative experiences, as this is their best opportunity to address obstacles and signal that they genuinely care about how clients feel.

Therapists may struggle to request feedback due to a fear of criticism, but this is an ideal opportunity to reflect on their practice and understand their clients on a deeper level. Therapists should view their therapy skills as a work in progress and challenge any problematic thinking that may be preventing them from seeking feedback.

By encouraging honesty and open communication, therapists can also equip clients with powerful skills that they can apply to their other relationships.

Therapists should calibrate their clinical intuition with client feedback

Therapists can also use structured feedback tools, like outcome measures, to gain comprehensive and objective insights. These tools provide a standardized way to collect, analyze, and interpret client feedback. This helps therapists make sense of the feedback and ensure they are attuned to the right kind. By incorporating feedback tools, therapists can transform the feedback process, ensuring it is not just heard but also effectively implemented.

Therapists' clinical intuition is also important in the counseling process. Intuition can be defined as "something that is known or understood without proof or evidence". It is a counselor's rapid, nonconscious insight into what is going on in a client's mind or behavior. Counselors can develop their intuition by working towards greater awareness of their "gut moments" and becoming conscious, skilled observers. They should also strive for a combination of intuition and theory in their practice, using their intuition as a hypothesis that is subject to testing and confirmation.

Therapists should be authentic and creative when implementing progress monitoring

• Progress monitoring allows therapists to be more responsive to patient needs on a session-by-session basis. It also contributes to empowering patients and enhancing their role in therapy.
• Progress monitoring has been shown to improve patient outcomes. In a meta-analysis, Lambert and Shimokawa (2011) found that patient outcome monitoring with feedback to the therapist was significantly associated with positive patient outcomes. Notably, the number of patients who deteriorated was halved by using a progress monitoring system.
• Collecting valid information about progress and outcomes through psychometric assessment allows therapists to address their ethical obligation to evaluate the services they provide. For example, the Canadian Code of Ethics for Psychologists states that psychologists are expected to "monitor and evaluate the effect of their activities, record their findings and communicate new knowledge to relevant others".
• Progress monitoring is an opportunity for organized networks of clinical practice to engage in enhanced program evaluation and psychotherapy research.
• Progress monitoring can be a tool for therapists to regulate their clinical intuition and improve both certainty and accuracy in their clinical decision-making process.
• Progress monitoring can help therapists grow in their profession by increasing their tolerance of clients' negative emotions and improving their ability to contain and address these difficult feelings.
• Progress monitoring can also help therapists become more open and transparent in testing their hypotheses, through both confirmation and disconfirmation.

Therapists should use progress monitoring to shape the future of the field

Therapists should use progress monitoring as it serves as a roadmap for their clients' self-discovery and healing. It also helps therapists and clients to set realistic goals and assess whether therapy is working. Furthermore, it helps clients to develop a sense of self-awareness and self-reflection as they become more attuned to their own experiences and learn to recognise triggers and warning signs.

Therapists should be aware that making progress in therapy is not a linear journey and that it often takes time. Progress can take weeks, months, or even longer, depending on the client's circumstances and what they want to achieve through therapy. However, research shows that most people who go to therapy experience relief from their symptoms and are able to function better, with about 75% showing some benefit.

• Note the client's "starting point" by reflecting on their current emotional state and overall well-being before beginning therapy.
• Work with the client to set clear and achievable goals.
• Encourage clients to check in with their feelings regularly and identify triggers.
• Note any changes in how the client is feeling and tailor the treatment plan accordingly.
• Encourage clients to seek feedback from trusted friends or family members to gain an external perspective on their progress.
• Maintain open and honest communication with the client to ensure a strong relationship and help identify any challenges.
• Consider keeping a source of truth on progress, such as a therapy journal, to help the client and therapist reflect on their progress over time.

By using progress monitoring, therapists can help their clients see the progress they have made and make any necessary adjustments to their treatment plan. This will ensure that the client is on track to reach their goals and make the most of their time in therapy.

Frequently asked questions